Prescription opioid drug abuse is epidemic in the US and accidental opioid-related overdose is one of the leading causes of preventable death among young people. Most opioid prescribing occurs in primary care where chronic pain patients also present with substance abuse and other mental health problems that put them at heightened risk for adverse clinical outcomes. A computerized decision support system (ATHENA-Opioid Therapy, OT) can automatically provide primary care providers guideline-concordant pain management recommendations to improve safety in opioid prescribing, but providers are reluctant to use the decision support system due to time constraints and discomfort in discussing problematic opioid use with their patients. Our group is well-positioned to intervene to improve safety in pain management for veterans. We recently demonstrated a strong association between post-deployment mental health problems and high-risk prescription opioid use and adverse outcomes in Iraq and Afghanistan veterans (Seal, Cohen, JAMA, 2012). Soon, our primary care clinics at the San Francisco VA Medical Center will become a demonstration site for the implementation of ATHENA-OT through a VA Patient Safety Center grant. Finally, we have begun to develop a series of Motivational Interviewing (MI) sessions to facilitate the communication of ATHENA-OT recommendations to chronic pain patients. We now propose to combine and leverage these building blocks to develop a new multi-level intervention that targets the system (Collaborative Care), primary care provider (computerized decision support for opioid therapy) and veteran (Care Manager-delivered Motivational Interviewing) to reduce problematic prescription opioid use and encourage non-opioid pain management alternatives. The main aim of this R34 project is to iteratively develop and test the acceptability feasibility, and preliminary efficacy of a Collaborative Care intervention in which a Care Manager will assist primary care providers (PCPs) by using Motivational Interviewing to communicate ATHENA-OT decision support guidelines to veterans with chronic pain. Specifically, after honing the intervention, we will conduct a pilot randomized controlled trial of Collaborative Care/Motivational Interviewing in 100 veterans with chronic pain in primary care who are prescribed opioid pain medications and exhibit at least one "high-risk" opioid use behavior (e.g. obtaining early opioid refills, etc.). Using ATHENA-OT decision support, PCPs will make guideline-concordant recommendations to all enrolled study patients and initiate a Pain Care Plan. Veterans randomized to Collaborative Care, will have one in-person MI session with the study Care Manager followed by 3 Care Manager-delivered telephones MI/monitoring sessions;patients randomized to the Attention Control arm will meet briefly with the Care Manager, followed by 3 Care Manager-delivered neutral telephone sessions. Findings from this study will support a multi-site R01 trial of a well-honed intervention to improve safe opioid prescribing and pain management for veterans in primary care.
Prescription opioid misuse has reached epidemic proportions and most opioid prescribing occurs in primary care where many chronic pain patients, including veterans, also present with substance abuse and other mental health problems that put them at very high risk for adverse clinical outcomes, such as opioid overdose. A computerized decision support system has been developed to automatically provide primary care providers guideline-concordant opioid prescribing recommendations at the point-of-care, but primary care providers are reluctant to use the system due to time constraints and personal discomfort in communicating with patients about problematic opioid use. The main aim of this NIDA/DoD R34 project is conduct a pilot randomized controlled trial to test the acceptability, feasibility, and preliminary efficacy of a Collaborative Care intervention in which a Care Manager assists primary care providers by using Motivational Interviewing to communicate decision support guidelines to veterans to improve safety in opioid prescribing and pain management.